Hypophosphatasia: presentation and response to asfotase alfa

Hypophosphatasia (HPP) is a rare bone disease with limited scientific evidence on the tolerability and safety of its novel treatment, Asfotase Alfa (AA). We report 7 HPP patients' heterogenous presentations and the significant improvement in various clinical outcomes attained with AA shedding light on this highly effective and safe therapy.

INTRODUCTION

Hypophosphatasia (HPP) is a rare inherited metabolic bone disorder characterized by a deficiency in the tissue non-specific alkaline phosphatase (TNSALP) due to loss of function mutation in the ALPL gene. HPP is associated with impaired skeletal mineralization due to elevations in inorganic pyrophosphate and altered phosphate : pyrophosphate ratio. Asfotase alfa (AA) "enzyme replacement" was approved for treatment of HPP in 2015. We present 7 patients with HPP, 5 with pediatric-onset, and 2 with adult-onset, who have been treated with AA and describe the efficacy and safety in these patients.

METHODS

7 patients (4 females, 3 males) aged 19-68 years with HPP were included in this study. Diagnosis of HPP was confirmed by DNA analysis. AA was administered in doses of 6mg/kg/week with a mean follow-up of 6 months (SD= 5).

RESULTS

Subjective improvement in muscle strength, muscle pain, walking ability, and walking distance with a reduction in the use of gait aids was seen "with AA in HPP patients." Muscle strength and pain improved by up to 70% from baseline as quantified subjectively by patients. Walking distance improved by up to 100%. Patients also reported improved cognition, mood, and energy levels, with up to 90% improvement in mood and 75% improvement in energy levels. 4 out of 6 patients first noted clinical signs of improvement after 3 months of being on therapy. 1 out of the 7 patients sustained a toe fracture 10 months from being on AA. AA was well-tolerated with injection site reactions being the most reported adverse effect.

CONCLUSION

HPP treatment with AA in individuals with both pediatric and adult-onset forms resulted in significant subjective improvement in musculoskeletal and cognitive manifestations in addition to patients' quality of life. The drug was well tolerated in 6 patients. 1 patient discontinued therapy because of minor adverse effects with myalgias.

Analytical assessment of clinical sensitivity and specificities of pharmaceutical rapid SARS-CoV-2 detection nasopharyngeal swab testing kits in Pakistan

Despite of the global unity against COVID-19 pandemic, the threat of SARS-CoV-2 variants on the lives of human being is still not over. SARS-CoV-2 pandemic has urged the need of rapid viral detection at earliest. To cope with gradually expanding scenario of SARS-CoV-2, accurate diagnosis is extremely crucial factor which should be noticed by international health organizations. Limited research followed by sporadic marketing of SARS-CoV-2 rapid pharmaceutical detection kits raises critical questions against quality assurance and quality control measures. Herein we aimed to interrogate effectivity and specificity analysis of SARS-CoV-2 pharmaceutical rapid detection kits (nasopharyngeal swab based) using conventional gold standard triple target real-time polymerase chain reaction (USFDA approved). A cross-sectional study was conducted over 1500 suspected SARS-CoV-2 patients. 100 real time-PCR confirmed patients were evaluated for pharmaceutical RDT kits based upon nasopharyngeal swab based kits. The SARS-CoV-2 nasopharyngeal swab based rapid diagnostic kit (NSP RDTs) analysis showed 78% reactivity. Among real time PCR confirmed negative subjects, 49.3% represented false positivity. The positive predictive analysis revealed 67.82%, while negative predictive values were 64.40%. The NSP RDTs showed limited sensitivities and specificities as compared to gold standard real time PCR. Valid and authentic detection of SARS-CoV-2 is deemed necessary for accurate COVID-19 surveillance across the globe. Current study highlights the potential consequences of inadequate detection of SARS-CoV-2 and emerging novel mutants, compromising vaccine preventable diseases. Current study emphasizes need to wake higher authorities including strategic organizations for designing adequate measures to prevent future SARS-CoV-2 epidemics.

Oleuropein, a phenolic component of Olea europaea L. ameliorates CCl4-induced liver injury in rats through the regulation of oxidative stress and inflammation

OBJECTIVE

This study aimed to assess the hepatoprotective role of oleuropein (Olp), a phenolic compound found in olive, against carbon tetrachloride (CCl4)-induced liver damage in rats.

MATERIALS AND METHODS

The research involved male albino rats, which received intraperitoneal injections of 100 mg/kg b.w. of oleuropein for 8 consecutive weeks before being subjected to carbon tetrachloride (CCl4) at a dosage of 1.0 ml/kg b.w. Changes induced by CCl4 in antioxidant and inflammatory marker levels were assessed using ELISA assay kits. Moreover, CCl4-induced liver tissue architecture alteration, fibrosis, and expression pattern of protein were evaluated by performing H&E, Sirius red, Masson trichrome, and immunohistochemistry staining.

RESULTS

Increased serum transaminases and massive hepatic damage were observed by this liver toxicant. The hepatic injury was further evidenced by a significant decrease in antioxidant enzyme activity [superoxide dismutase (SOD), glutathione peroxidase (GPx), Glutathione (GSH) and Total Antioxidant Capacity (T-AOC)]. The administration of CCl4 resulted in an increased inflammatory response, which was measured by C-reactive protein, interleukin-6, as well as tumor necrosis factor-alpha. Olp as a curative regimen led to significant attenuation in the inflammatory response and oxidative/nitrosative stress. This polyphenol treatment improved the hepatic tissue architecture and decreased fibrosis. In the CCl4 treatment group, the expression pattern of IL-6 protein was high, whereas expression was decreased after Olp, as evidenced by immunohistochemistry staining.

CONCLUSIONS

The study suggests that oleuropein treatment has the potential to reduce liver damage caused by CCl4 induction by inhibiting oxidative stress and inflammation and maintaining liver tissue architecture. This could make it a promising treatment option for liver pathogenesis.

Gastric Electrical Stimulation for the Treatment of Gastroparesis or Gastroparesis-Like Symptoms: A Systemic Review and Meta-Analysis

BACKGROUND

The effects of gastric electrical stimulation are not fully understood. We aimed to assess the efficacy of gastric electrical stimulation (GES) for patients with gastroparesis and gastroparesis-like symptoms.

MATERIALS AND METHODS

We searched PubMed, Scopus, Cochrane, Web of Science, Embase, and Science Direct to identify controlled trials and cohort studies. We used random effects models to estimate pooled effects. A total of nine studies met the criteria and were included for the final qualitative synthesis and the quantitative analysis. We examined the mean absolute differences (MD) and 95% CIs.

RESULTS

Nine studies (n = 730) met the criteria and were included for the final qualitative synthesis and the quantitative analysis. There was significant improvement in gastrointestinal (GI) total symptom score (TSS) with the GES group compared with controls during the randomized blind trials. This effect was sustained at 12 months after treatment compared with before treatment (MD = -6.07; 95% CI, -4.5 to -7.65; p < 0.00001). The pooled effect estimate showed a significant improvement in frequency of weekly vomiting episodes at 12 months compared with before treatment (MD = -15.59; 95% CI, -10.29 to -20.9; p < 0.00001).

CONCLUSION

GES appears beneficial, with significant improvement in GI TSS, weekly vomiting frequency, gastric emptying study, and quality of life.

Disinfection by methylthionine chloride and chitosan in combination with Photo radiation therapy on caries affected dentin nano hardness, adhesive integrity, and bond failure

OBJECTIVE

The aim of the study was to assess the disinfection efficacy, bond integrity, and nano hardness of caries-affected dentin (CAD) surface bonded to resin cement when disinfected with chlorhexidine (CHX), Methylene blue activated by Photodynamic therapy (MB-PDT), chitosan, silver diamine fluoride (SDF), chitosan activated by PDT, and SDF-diode laser against S. mutans.

MATERIALS AND METHODS

A total of 60 human mandibular molars were extracted non-traumatically and gathered using ICDAS criteria. The dentin surface was prepared, leaving CAD to receive a disinfection procedure. After inoculation with S. mutans, the CAD samples were divided into six groups and disinfected with various disinfectants (n = 10) CHX, MB-PDT, chitosan, chitosan-PDT, SDF, and SDF+ diode laser. Survival rates of S. mutans were analyzed following the restoration of samples with resin cement via the etch and rinse method to assess SBS. Also, nano hardness was analyzed. Statistical analysis was performed by using the ANOVA and the Tukey multiple test (p<0.05). The Kruskal-Wallis test was used to evaluate the change in survival rate.

RESULTS

Related to the survival rates, the SDF+ diode laser displayed the highest reduction in S. mutans levels and chitosan presented the lowest level of disinfection. The intergroup comparison revealed that CHX and chitosan-PDT displayed comparable outcomes of S. mutans survival rate to that of SDF+ diode laser (p>0.05). Likewise, MB-PDT and SDF displayed a comparable survival rate of S. mutans to Chitosan disinfection (p>0.05). Considering SBS and nano hardness, the highest SBS and NH were exhibited by the SDF+ diode laser, and the lowest SBS and NH values were exhibited by MB-PDT. The intragroup comparison revealed that CAD specimens disinfected with Chitosan-PDT showed comparable SBS and NH values to the SDF+ diode laser (p>0.05). CHX, chitosan, and SDF exhibited bond values and NH comparable to MB-PDT (p<0.05).

CONCLUSIONS

Synergistic use of Silver diamine fluoride with diode laser and chitosan activated by PDT can be used as an alternative to CHX for controlling S. mutans growth, promoting enhanced bond efficacy and nano hardness for bonding resin cement to the caries-affected dentin.

Ammonia gas treatment in low cost biological reactor

Ammonia gas contributes to a number of environmental and human health concerns. The use of chalk, a cheap alkalinity source may reduce costs for biological systems. This research studies a closed liquid flow reactor to treat ammonia gas using chalk as biomass media and alkalinity source with high value calcium nitrate fertilizer production. The proposed reactor showed complete ammonia gas removal at high rate (500 mg N/L/day) and with low cost; where chalk dissolution and ammonia gas absorption contributed to alkalinity in the water for nitrification. High calcium ion concentration (up to 10,000 mg Ca2+ as CaCO3/L) showed only minor effects on ammonia absorption and nitrification rate.

Mechanical Control of Polaritonic States in Lead Halide Perovskite Phonons Strongly Coupled in THz Microcavity

We demonstrate the generation and control of polaritonic states in perovskite phonon polaritons, which are strongly coupled in the middle of a flexible Fabry-Perot cavity. We fabricated flexible perovskite films on a microporous substrate coated with graphene oxide, which led to a virtually free-standing film incorporated into the microcavity. Rabi splitting was observed when the cavity resonance was in tune with that of the phonons. The Rabi splitting energy increased as the film thickness increased, reaching 1.9 meV, which is 2.4-fold higher than the criterion for the strong coupling regime. We obtained dispersion curves for various perovskite film thicknesses exhibiting two polariton branches; clear beats between the two polaritonic branches were observed in the time domain. Flexible cavity devices with perovskite phonons enable macroscopic control over the polaritonic energy states through bending processes, which add an additional degree of freedom in the manipulation of polaritonic devices.

Hepatitis C virus associated ALT, AST, GGT, Bili T, HB, HBA1C, CREAT, PT, aPPT, AFP, CEA, CA 125, CA 19-9, iPTH biomarkers, computed tomography and HCV burden of disease during pre COVID-19 era (2018-2019) and post COVID-19 era (2020-2022) in Pakistan

The national burden of HCV has significantly mounted over the period of last few decades placing Pakistan at the worst placement of second largest burden of HCV globally. Herein for the first time from Pakistan, we examined clinical correlation of potential biomarkers with HCV. Nation-wide study was conducted on 13,348 suspected HCV patients during 2018-2022. During pre-COVID-19 era of 2018-2019, prevalence of HCV remained 30%. During 2018, among HCV positive patients, 91% of ALT, 63% of AST, 67% of GGT, 28% of Bili T, 62% of HB, 15% of HBA1C, 25% of CREAT, 15% of PT, 15% of aPTT and 64% of AFP were abnormal. During 2019, among HCV infected 74.47% of ALT, 63.54% of AST, 70.24% of GGT, 24.71% of Bili T, 8.77% of HB and 75% of AFP were raised. CT/CAT scan revealed 4.65% liver complications (mild 13.04%, moderate 30.43% and severe 56.52%). During 2020, HCV prevalence remained 25%. 65.17% of ALT, 64.20% of AST, 68.75% of GGT, 31.25% of Bili T, 20.97% of HB, 4.65% of CREAT and 73.68% of AFP levels were raised. CAT analysis revealed liver complications among 4.41% (14.81% mild, 40.74% moderate, and 44.44% sever). 85.71% of participants diabetes was out of control. During 2021, HCV prevalence remained 27.1%. ALT (73.86%), AST (50.6%), GGT (67.95%), Bili T (28.21%), HB (20%), CREAT (5.8%) and AFP (82.14%) levels were abnormal. During 2022, the levels of ALT (56.06%), AST (56.36%), GGT (56.6%), Bili T (19.23%), HB (43.48%), HBA1C (14.81), CREAT (18.92%), AFP (93.75%) were abnormal. CAT analysis revealed 7.46% liver complications (25% mild, 30.36% moderate, and 42.86% sever). During 2021-2022, 83.33% of subject's diabetes was not controlled.

Evaluation of histo-toxicity of nimesulide in Black Kites (Milvus migrans): a pharmacodynamic study

The present experimental work was conducted to elucidate the toxicity of nimesulide at three different doses in black kites (Milvus migrans). M. migrans is one of the most common raptors near human habitations. The goal of the current investigation was to determine whether nimesulide is similarly hazardous to raptors as was diclofenac sodium and to investigate the acute oral toxicity of nimesulide in these birds. For this study, eight adult male black kites (M. migrans) were randomly divided into four groups. M. migrans in the control group (n = 02) were not treated with nimesulide. The other three groups were given nimesulide doses. The birds in the first (n = 02) were declared the control group. The second (n = 02), third (n = 02), and fourth groups were administered nimesulide at a low, medium, and high dose of 2, 4, and 6 mg/kg live body weight of bird/day, respectively, for 10 days. Nimesulide-addled birds became listless and despondent, then anorexic. The birds were standing there with their eyes closed and showing no signs of life. There was an increase in saliva production, a slowing of breathing, and dilated pupils. No clinical signs were observed in the control group. No mortality was seen in the control or treated groups. The control group did not show lesions of gout, but black kites intoxicated with nimesulide at 2, 4, and 6 mg/kg live body weight of bird/day showed inflammation, apoptosis, hemorrhage, necrosis, and leukocytic infiltration tissues of the liver, kidney, and heart of black kites (M. migrans) treated with different concentrations of nimesulide. The treated groups also showed apoptosis of myofibrils and hyperplasia. The hypertrophy, atrophy, fibrosis, necrosis of skeletal muscles and hemorrhage were prominent in the muscles of black kites (M. migrans) intoxicated with nimesulide. All observed histological alterations got worse in a dose-related way. There was no significant difference in AST, ALT, ALP, serum uric acid, but a significant difference was observed in the values of serum urea (p = 0.001) and serum creatinine (p = 0.019).

A novel scoring system to predict cardiac device implantation in patients presenting with syncope

Background

Cardiac syncope occurs when the heart fails to maintain cardiac output to match cerebral need and can occur due to either mechanical/structural defect of the heart or secondary to an arrhythmia. It has a raised 1-year mortality with some figures estimating this as high as 30%. Implantable loop recorders (ILR) are a useful diagnostic tool in patients presenting with syncope or pre-syncope to ascertain a cardiac cause. A higher number of patients are presenting with advancing age and undergoing ILR implantation. Subsequently, they end up requiring a cardiac implantable electronic device (CIED) implantation, adding to additional costs, exposure to procedural complications and frequent hospitalisations.

Purpose

To investigate the number of patients undergoing CIED implantation following implantation of ILRs for syncope and identify predictors of CIED implantation in patients presenting with syncope.

Methods

A retrospective analysis of 736 patients who underwent ILR implantation at our teaching hospital trust between November 2012 to October 2020. Data on demographics, clinical characteristics, pathology results, ECGs, holter findings and CIED implanted was collected using the local electronic patient record system. The data was analysed using SPSS software. Univariable and multivariable regression analysis and ROC curve analysis was carried out to determine prediction model for CIED implantation.

Results

The mean age of patients who underwent an ILR implantation was 65±19 years. 22% of patients required CIED implantation, 68% of patients did not require a cardiac device and were safely discharged and 10% of patients died during follow up. Age (p&lt;0.001), male sex (p=0.006), impaired left ventricular function (p=0.04) and presence of hypertension (p=0.04) were found to be independent predictors of CIED implantation on univariable and multivariable regression analysis (see Table 1).

Conclusions

Old age, presence of coronary artery disease, impaired left ventricular function and presence of hypertension are inter-linked and in our study were found to be key predictors of poor prognosis and thus requiring CIED implantation. We propose a scoring system based on age &gt;75, male sex, presence of ischaemic heart disease, heart failure and hypertension as key markers of conduction abnormalities requiring CIED implantation (see fi−ure 1).

Funding Acknowledgement

Type of funding sources: None.

163 Anterior Sacral Meningocystocele Manifesting as Vague Gastrointestinal and Urinary Syndromes – Two Case Reports

Aim

Anterior Sacral Meningocystocele (ASM) carries a unique place in the current literature regarding its rarity. The condition arises in association with a congenital defect of the sacrum and coccyx through which the caudal part of the meninges may herniate to form a cyst-like structure. The disorder derives from a genetic defect of the coccyx and sacrum of which some meningeal segments protrude or herniate, forming a cyst-like entity.

Method

We report two cases of ASM. The first is a 65-year-old male with active complaints of urinary retention and hesitancy for two weeks and chronic constipation associated with lower back pain. The second, a 17-year-old girl, was presenting with abdominal bloating, pain, and backache. Magnetic resonance imaging (MRI) of the pelvis and lumbosacral spine was conducted for both patients, respectively, each scan exhibiting evidence of ASM development. Surgical correction and closure of the ASM's were performed via a posterior midline approach, which successfully alleviated the symptoms presented clinically by both patients.

Conclusions

ASM may develop asymptomatically, often with incidental discovery. Although ASM is well-regarded as a rare anomaly, diagnosis of such a defect must always be kept pertinent when a cystic structure in the pelvis is unveiled on ultrasound or during surgery. Puncture or aspiration of the cyst should be avoided if the diagnosis is in doubt. A posterior midline approach with careful obliteration of the meningocele sac opening may be curative.

Drought stress enhances the efficiency of floral dip method of Agrobacterium-mediated transformation in Arabidopsis thaliana

The Agrobacterium-mediated floral dip protocol is the most extensively used transformation method for a model plant Arabidopsis thaliana. Several useful methods for Agrobacterium tumefaciens-mediated transformations of Arabidopsis are existing, but they are time consuming and with low transformation efficiency. Here, we developed a transgenic Arabidopsis lines TET12p::TET12-RFP in a short period of time and enhanced transformation efficiency by using a modified transformation method by applying drought stress after floral dip. In this protocol, Agrobacterium cells carrying TET12p::TET12-RFP recombinant vectors were resuspended in a solution of 5% sucrose, 0.05% (v/v) silwet L-77 to transform female gametes of developing Arabidopsis inflorescences. Treated Arabidopsis were then applied with different levels of drought stresses to stimulate plants for the utilization of maximum plant energy in seed maturation process. The applied stresses achieved the fast maturation of already treated inflorescences while stopped the growing of newly arising untreated inflorescence, thus decreased the chances of wrong collection of untransformed seeds. Consequently, the collected seeds were mostly transgenic with a transformation frequency of at least 10%, thus the screening for positive transformants selection was more advantageous on a selective medium as compared to a classical floral dip method. Within 2-3 months, two hundred of individual transgenic plants were produced from just 10 infiltrated plants. This study concludes that application of drought stresses in a specific stage of plant is a beneficial strategy for achieving the transgenic Arabidopsis in a short period of time with high transformation efficiency.

Magnesium sulfate as a potential dye additive for chlorophyll-based organic sensitiser of the dye-sensitised solar cell (DSSC)

In this work, a new chlorophyll dye-sensitiser derived from mitragyna speciosa (MS) leaves, also known as Kratom, was employed for dye-sensitised solar cells (DSSCs). The influence of magnesium sulfate (MgSO₄), a low-cost dye additive, and suitable extraction solvents on the performance of DSSCs were examined. Here, the optical properties were investigated using UV-Visible spectroscopy and the functional anchoring group were investigated by FTIR spectroscopy. Meanwhile, the photovoltaic parameters were investigated by I-V measurements. The highest conversion efficiency is obtained when using a dye extracted from methanol solvent in combination with MgSO₄ additive, namely methanolic magnesium sulfate (MMSO). This higher power conversion efficiency is mainly attributed to the enhancement of the hydroxyl group in the MMSO dye solutions, which promotes higher dye adsorption and provides an organic dye passivation layer that reduces back-recombination in the cell. Furthermore, MgSO₄ aids in the replenishment of magnesium lost in the chlorophyll porphyrin ring during the degradation process. These combined effects have contributed to the overall conversion efficiency of the MMSO cell at 0.26 %, followed by 0.24 % for ethanolic magnesium sulfate (EMSO), respectively.

Study of resveratrol against bone loss by using in-silico and in-vitro methods

By applying the in-silico method, resveratrol was docked on those proteins which are responsible for bone loss. The Molecular docking data between the resveratrol and Receptor activator of nuclear factor-kappa-Β ligand [RANKL] receptors proved that resveratrol binds tightly to the receptors, showed the highest binding affinities of -6.9, -7.6, -7.1, -6.9, -6.7, and -7.1 kcal/mol. According to in-vitro data, Resveratrol reduced the osteoclasts after treating Marrow-Derived Macrophages [BMM] with Macrophage colony-stimulating factor [MCSF] 20ng / ml and RANKL 50ng / ml, with different concentrations of resveratrol (2.5, 10 μg / ml) For 7 days, the cells were treated with MCSF (20 ng / ml) and RANKL (40 ng / ml) together with concentrated trimethyl ether and resveratrol (2.5, 10 μg / ml) within 12 hours. Which, not affect cell survival. After fixing osteoclast cells with formaldehyde fixative on glass coverslip followed by incubation with 0.1% Triton X-100 in PBS for 5 min and after that stain with rhodamine phalloidin staining for actin and Hoechst for nuclei. Fluorescence microscopy was performed to see the distribution of filaments actin [F.actin]. Finally, resveratrol reduced the actin ring formation. Resveratrol is the best bioactive compound for drug preparation against bone loss.

Dietary habits of lesser bandicoot rat (Bandicota Bengalensis) in an agro-ecosystem, Pothwar Plateau, Pakistan

Dietary habits of bandicoot rats (bandicota bengalensis) were investigated in the agricultural crops of the Pothwar Plateau, Pakistan by analysing stomach contents. The research activities were conducted in major field crops including wheat-groundnut and in the fallow lands during non-crop season at the field boundaries. The specimens were captured from the fields using kill/snap traps, and dissected to collect their stomach samples for laboratory analysis. Light microscopic slides of the plant material were recovered from stomach samples and the reference materials were collected from the field. Results revealed that the bandicoot rat predominantly fed upon cultivated crops during cropping season but consumed wild vegetation during non-cropping season. There was no significance difference between summer and winter diets. Most frequently consumed crop food items were wheat (Triticum aestivum; 28.57%), groundnut (Arachis hypogea; 11.26%), sorghum (Sorghum bicolor; 10.17%), chickpea (Cicer arietinum; 9.52%), maize (Zea mays; 6.49%), millet (Pennisetum glaucum; 5.84%), barley (Hordeum vulgare; 4.98%) and mustard (Brassica campestris; 4.98%). Among wild vegetation were consumed khbal gha (Cynodon dactylon; 7.79%), baron dhab (Demostachya bipinnata; 7.36%) and Prickly flower (Achyranthes aspera; 3.03%). The study concludes that, in addition to consuming wheat and groundnut crops, the Lesser bandicoot rat also subsists on grasses, weeds, and some fodder crops, as important component of its diet in agro-ecosystem of the Pothwar Plateau.

Death caused by covid-19 in top ten countries in Asia affected by covid-19 pandemic with special reference to Pakistan

The COVID-19 is a contagious viral disease, was first emerged in Wuhan, China in December 2019 and became the whole world on alert. The mortality rate in top most countries in Asia with special reference to Pakistan has been focused. Since February 26 to September 2020 the total confirmed cases and mortality rate was measured through Wikipedia and the notable journals. Iran is the only country having highest number of deaths (5.73%) followed by Indonesia (3.77%) while Saudi Arabia shows the lowest number of deaths as 1.39%. In Pakistan the first case was confirmed in 26th February, 2020. The nCov-19 has closely related to severe acute respiratory syndrome (SARS) hence SARS COV-2 was named. This virus is responsible for more than 33.9 million deaths in over all the world as of 20th September, 2020. The number of new cases is increasing time to time. Sindh province of Pakistan has reported the highest number of cases till September, 20, 2020 as compared to other parts of the country and has the highest number of death followed by Khyber Pakhtunkhwa. Because of the person to person contact the disease is spreading rapidly. The individuals who has already infected with other diseases like cancer or diabetic etc. are vulnerable. The nCOV-19 is the most contagious due to its mode of transmission. There is still no vaccine is available for the treatment of disease caused by nCoV-2019. It is therefore the only option to control this pandemic is to adopt effective preventive measures.

Three-dimensional simulation of aesthetic outcome from breast-conserving surgery compared with viewing photographs or standard care: randomized clinical trial

INTRODUCTION

Over half of women with surgically managed breast cancer in the UK undergo breast-conserving treatment (BCT). While photographs are shown prior to reconstructive surgery or complex oncoplastic procedures, standard practice prior to breast conservation is to simply describe the likely aesthetic changes. Patients have expressed the desire for more personalized information about likely appearance after surgery. The hypothesis was that viewing a three-dimensional (3D) simulation improves patients' confidence in knowing their likely aesthetic outcome after surgery.

METHODS

A randomized, controlled trial of 117 women planning unilateral BCT was undertaken. The randomization was three-way: standard of care (verbal description alone, control group), viewing two-dimensional (2D) photographs, or viewing a 3D simulation before surgery. The primary endpoint was the comparison between groups' median answer on a visual analogue scale (VAS) for the question administered before surgery: 'How confident are you that you know how your breasts are likely to look after treatment?'

RESULTS

The median VAS in the control group was 5.2 (i.q.r. 2.6-7.8); 8.0 (i.q.r. 5.7-8.7) for 2D photography, and 8.9 (i.q.r. 8.2-9.5) for 3D simulation. There was a significant difference between groups (P < 0.010) with post-hoc pairwise comparisons demonstrating a statistically significant difference between 3D simulation and both standard care and viewing 2D photographs (P < 0.010 and P = 0.012, respectively).

CONCLUSION

This RCT has demonstrated that women who viewed an individualized 3D simulation of likely aesthetic outcome for BCT were more confident going into surgery than those who received standard care or who were shown 2D photographs of other women. The impact on longer-term satisfaction with outcome remains to be determined.Registration number: NCT03250260 (http://www.clinicaltrials.gov).

Feasibility of youth empowerment initiative for identifying never- and under-immunized children

Background

One-in-every 5 children globally remains deprived of life-saving vaccines. We developed and implemented the Adolescent Health and Leadership Program (AHLP) among school girls from grades 8-10 (Kiran Sitaras (KSs); Shining Stars) to provide them with soft skills and community mobilization skills and equipping them to become community advocates for immunization. We evaluated the feasibility of KS community mobilization through validating KSs' ability to accurately identify and link never- and under-immunized children with immunization services.

Methods

We implemented a mixed-methods study in six public schools located in peri-urban areas of Karachi, Pakistan. After the development and roll-out of AHLP in schools, KSs conducted door-to-door visits in their neighborhoods to identify never-and under-immunized children. This was followed by verification visits by field staff to establish accuracy and immunization camps to vaccinate never- and under-immunized children identified by KSs.

Results

From January 28 to February 22, 2020, 591 KSs visited 10,330 households, screened 3,295 under-2 children and identified 7.5% (247/3,295) never- and 27.0% (889/3,295) under-immunized children, with an accuracy of 90.4% and 49.6%, respectively. In January 2021, 291 never- and under-immunized children were invited to immunization camps, of which 28.9% (84/291) received vaccinations, while 57.0% (166/291) did not respond to the invite and 14.1% (41/291) were deemed ineligible (illness, overage, etc.).

Conclusions

We demonstrated the feasibility of empowering adolescent girls to boost immunization uptake in LMIC settings. Engaging young women from within the community provides an organic and sustainable solution for promoting immunization coverage and equity today and ensuring they will continue to champion the cause in their capacity as tomorrow's mothers. We are actively scaling-up our solution across the country to create a force of 100,000+ KSs to magnify our efforts.

Key messages

The Kiran Sitara initiative, via its community-centered approach, leverages the force of adolescent school girls to boost demand and referrals for immunization in unreached geographical pockets. The Kiran Sitara initiative utilizes the power of youth engagement to identify never- and under-immunized children, and subsequently increase vaccine-uptake.

Feasibility of an artificially intelligent vaccines chatbot in Pakistan: A mixed methods evaluation

Background

Despite free vaccination services, gaps in information access impede immunization uptake in low and middle-income countries (LMICs), including Pakistan. We developed Bablibot (Babybot), a local-language, text-based chatbot to connect caregivers with immunization-related information in real-time, and evaluated its feasibility and acceptability in resolving immunization-related queries among Karachi's low-income communities.

Methods

We developed Bablibot using Natural Language Processing (NLP), Machine Learning, and Human in the Loop features. We conducted a sequential mixed-methods pilot in Karachi where caregivers were recruited when visiting selected immunization centers for any childhood vaccine except Measles 2 (last vaccine visit) or were informed through targeted text messages. We assessed Bablibot's feasibility and acceptability through user-engagement metrics and thematic analysis of qualitative interviews conducted with 20 pilot participants.

Results

Between March 9, 2020 and April 15, 2021, Bablibot accrued 677 users and participated in 874 conversations. Of 2,202 pilot-enrolled caregivers, 210 (10%) interacted with the bot; other 467 users were not pilot participants. Most queries were about due dates (25%; 221/874), delaying vaccination (17%; 146/874), or side-effect management (16%;137/874). The conversations now constitute a valuable training database for future local-language bots. Over 90% (277/307) of responses to text-based exit surveys indicated user satisfaction. Qualitative analysis showed caregivers appreciate Bablibot's convenience, reliability, and responsiveness.

Conclusions

Our results demonstrate the feasibility and acceptability of local-language NLP chatbots in providing immunization information. Text-based chatbots can minimize workload on helpline operators, in addition to quickly resolving queries that otherwise lead to delay or default. Bablibot's conversation data provides learning infrastructure for future health-related bots.

Key messages

An AI-based NLP chatbot is a feasible and acceptable intervention for providing immunization-related information to large number of caregivers 24/7 in limited resource setting. By serving as a remote, low-cost and confidential bi-directional channel, chatbots can address gaps in information access, especially for women, and have long term impact on immunization uptake.

1-year impact of COVID-19 on childhood immunizations in Pakistan: analysis of &gt; 3.7 million children

 

Covid-19 has universally disrupted primary health care, but routine childhood immunizations are one the most affected services. We analyzed big data in vaccines for measuring the 1-year impact of Covid-19 on outline childhood immunizations for the 48 million population in the Sindh province of Pakistan. We extracted and analyzed >3.7m real-time immunization records of 0-23 months old children from the Sindh Government's Electronic Immunization Registry (EIR). Using a 6-month baseline preceding the COVID-19 lockdown, we quantified the lockdown's (March 23-May 9, 2020) impact on daily immunization rates by geographical area and the change in coverage rates at the one-year mark since the lockdown. The lockdown resulted in 53% drop in the number of immunizations. The impact in rural areas as more than in urban areas (54.9% decline vs 47.5% decline from baseline), and slums had a slightly larger decrease in immunization coverage than non-slum areas (53.8% vs. 51.3%). Of 1,246,321 children who missed immunizations during first year of the pandemic, 76% of these children were eventually vaccinated by the end of March 2021. Similarly, of the 417,553 children who had dropped out during the initial 7-week national lockdown (March 23-May 10, 2020), 79% were immunized by March 2021. Our analysis of EIR data shows that the catch-up and recovery of coverage rates have primarily been driven through intensive outreach vaccination efforts instead of an increase in demand. One year since the onset of the pandemic, the average daily immunization doses administered through outreach increased by 121 percent above baseline estimates. In contrast, vaccines administered at immunization clinics were still 22 percent below baseline. The example of Pakistan shows LMICs can successfully deploy mitigation strategies to catch up with missed children during Covid-19 and sustain routine childhood immunizations to close immunity gaps.

Key messages

Although the lockdown resulted in a 53% drop in immunizations, at the 1-year mark since the pandemic started, 76% of children who missed immunizations are vaccinated.

Pakistan data shows LMICs can rectify routine immunization coverage and immunity gaps and rebound successfully to their pre-COVID-19 coverage rates.

Prevalence of cestodes infection among school children of urban parts of Lower Dir district, Pakistan

Tapeworms of zoonotic importance have been described as a leading public health problem. Current research was aim to assess the prevalence of tapeworms among 5-12years school children residing in district Lower Dir, Pakistan from January 2019-December 2019. The wet mount preparation in saline/iodine/methods were used for stool examination. Data was analyzed using appropriate descriptive, static methods. Of the 400 children studied 71.7% were infected with one or more species of intestinal parasites. Single infection of cestode species was found in 69 individuals with 17.2% prevalence and multiple parasitic infections were identified in 19.7% (n=79/400) individuals. The multiple infection were comprised as 10% (n=40) double, 6.75% (n=27) triple and 3% (n=12) quadruple. A total of 9 species of helminths and one species of protozoan infection. Among the helminths Ascaris lumbricoides was the most prevalent 33.1% (n=95), Taenia saginata 22.6% (n=65), hookworm 19.8% (n=57), Hymenolepis nana 18.8% (n=54), Enterobius vermicularis and Hymenolepis diminuta 1.39% (n=4each), Trichuris trichura 1.04% (n=3), Toxocara spp 0.69% (n=2) and Schistosoma japonicum 0.34% (n=1) were reported. One protozoan species was Cryptosporidium spp 0.69% (n=2) in current study. In case of A.lumbricoides, hookworm, E.vermicularis, T.trichura, T.saginata, H.nana and H.diminuta the male children of below 8 years of age were highly infected. Other infections are reported in the same prevalence with slight difference if any. We conclude that there is a need for mass scale campaigns to create awareness regarding health and hygiene in children and the need for development of effective poverty control programs because deworming alone is not adequate to control parasitic infections.

Association between atrial high rate episode burden and autonomic and vascular function in patients with implanted cardiac device

Background

Patients who experience frequent atrial high rate episodes (AHREs), recorded on implantable cardiac devices, are at an increased risk of stroke and systemic embolism. Increased duration of AHRE is related to higher risk of thromboembolic event. The underlying pathophysiology is unclear; however, autonomic and/or endothelial dysfunction may contribute.

Purpose

We tested the hypothesis that patients with high AHRE burden have worse autonomic and vascular function compared to patients with low AHRE burden.

Design

We studied 44 patients split in two groups: high AHRE burden (longest AHRE ≥24 hours; n=22) and low AHRE burden (longest AHRE &lt;24 hours; n=22). Resting time- and frequency-domain measures of HRV were determined to index cardiac autonomic function. High-resolution ultrasound was used to measure brachial artery diameter at rest and during reactive hyperaemia (endothelium-dependent flow mediated dilation (FMD)).

Results

FMD was higher in the low AHRE burden group compared to high AHRE group (5.5% [95% confidence interval (CI):3.4–7.6] vs 3.1% [95% CI: 1.9–6.2]; p=0.04) (table 1). Mean heart rate (p&lt;0.001) and AHRE burden (p=0.02) were independent predictors of FMD on multivariate analysis. Time-domain, frequency-domain and non-linear indices of HRV were not significantly different between the groups. A slower heart rate (Spearman's rho 0.369; p=0.01) and high AHRE burden (Spearman's rho −0.315; p=0.04) were independently associated with changes seen on FMD following adjustment for multiple variables (p=0.001 and p=0.03 respectively).

Conclusion

Endothelium-dependent FMD is impaired in patients with high AHRE burden, while HRV derived indices of autonomic function were not affected by AHRE burden. Endothelial dysfunction may play an important role in the adverse outcomes seen in patients who experience frequent AHRE.

Funding Acknowledgement

Type of funding sources: None.

Self-Inflicted Pneumomediastinum: A Case Report

Self-inflicted wound can present with various scenarios. It is well known that the purpose of a self-inflicted wound is to avoid obligatory duties. During war, soldiers get self-inflicted wounds to seek medical leave in the hope to save their lives from deadly battle. Self-induced pneumomediastinum from oral lesion with valsalva maneuver was a rare practice among prisoners to get rid of that imprisoned life and to stay in the hospital. Self-inflicted wound is also commonly seen in patient with psychosomatic disorders. It relates observations from forensic medicine and psychiatry to specific clinical symptoms, toxicological circumstances and social influences e.g. stress incurred by everyday life, war, imprisonment etc. In particular cases, it clears up criminal and civil jurisdiction. It also gives importance to private insurers about cases of self-mutilation. There is also concern about insurers, forensic scientists and psychiatrist about their responsibilities and the procedure they follow in the examination, their jurisdiction and the treatment involving the cases of self-inflected injuries. To our knowledge, self-inflicted subcutaneous emphysema causing pneumomediastinum by a normal young boy out of curiosity and without any apparent ill motive, is an unusual finding and possibly no such case report was published before.

Wild birds trade in Dera Ismael Khan and Bannu divisions of Khyber PakhtunKhwa (KPK) Province, Pakistan

Wildlife trade is a profitable economic activity. Birds are among the most heavily traded animals worldwide, with numerous species threatened by pet trade. The present case study was stretched for period of one year to find out the status of wild birds' trade in Bannu and Dera Ismael Khan Divisions. The study was aimed to find out the types of species, commercial prices of bird, trade routes, overall income generated from birds' trade and the status of dealers whether licensed or not. Bimonthly visits were conducted to interview 52 bird dealers/pet shops owners/venders (23 in Dera Ismael Khan and 29 in Bannu). A sum of 16 conceivable sites were visited during the study period. Out of these, 8 sites were located in Dera Ismael Khan and 8 sites in Bannu Division. The highest priced species was Demoiselle crane (Grus virgo) and the lowest priced species was house sparrow (Passer domesticus). Total number of species traded in both regions were 8 and 14 while the income generated by bird trade was amounting to PkR 1,322,200 and 7,128,950 in Dera Ismael Khan and Bannu respectively. Majority of the birds were trapped locally with the exception of few from adjacent areas. Commercial activity led by illegal bird traders was found 75% and 100% species in Dera Ismael Khan and Bannu respectively. There was no significant difference between prices of birds, number of species sold and income generated by bird trade in two divisions.

Mosquitocidal activities of Chenopodium botrys whole plant n-hexane extract against Culex quinquefasciatus

This research aimed to investigate various mosquitocidal activities of Chenopodium botrys whole- plant n-hexane extract against Culex quinquefasciatus. The extract showed remarkable larvicidal, pupicidal, adulticidal, oviposition deterrent and adult emergence inhibitory activities against Cx. quinquefasciatus. During the larvicidal and pupicidal activities, the 24-hour lethal concentration (LC50) of extract against 2nd instar larvae, 4th instar larvae and pupae were 324.6, 495.6 and 950.8 ppm, respectively. During the CDC (Centers for Disease Control and Prevention) bottle bioassay for adulticidal activity, the median knockdown times (KDT50) at 1.25% concentration was 123.4 minutes. During the filter paper impregnation bioassay for adulticidal activity, the KDT50 value at 0.138 mg/cm2 concentration was 48.6 minutes. The extract was fractionated into 14 fractions through silica gel column chromatography which were then combined into six fractions on the basis of similar retention factor (Rf) value. These fractions were screened for adulticidal activity by applying CDC bottle bioassay. The fraction obtained through 60:40 to 50:50% n-hexanes-chloroform mobile phase with 0.5 Rf value showed 100% adulticidal activity at 0.2% concentration. During oviposition deterrent activity, the highest concentration (1000 ppm) showed 71.3 ± 4.4% effective repellence and 0.6 ± 0.1 oviposition activity index. During adult emergence inhibition activity, the median emergence inhibition (EI50) value was 312.3 ppm. From the outcome of the present investigation, it is concluded that the n-hexane extract of C. botrys whole- plant possesses strong larvicidal, pupicidal, adulticidal, oviposition deterrent and adult emergence inhibitory activities against Cx. quinquefasciatus.

Plant age, crop stage and surrounding habitats: their impact on sucking pests and predators complex in cotton (Gossypium hirsutum L.) field plots in arid climate at district Layyah, Punjab, Pakistan

Sucking pests are major threat to cotton field crop which cause unbearable losses to the crop yield. Aim of the current study was to record seasonal dynamics of major sucking insect pests including whitefly, jassid, thrips and their natural arthropod predators i.e. green lacewings and spiders in cotton field plots. The effects of surrounding field crops on pests' density and predatory efficiency of predators were also recorded. For sampling and survey of insects, the visual counting was found to be the most efficient method for recording the abundance of insects, trailed by net sweeping and tapping. Whitefly was the most dominant sucking pest found on the vegetative stage of cotton, followed by jassid and thrips. Fluctuated populations of predatory arthropods, spiders and green lacewings were also recorded during whole cropping season however, the densities of pests and predators varied with crop phenology. Spiders' population was encouraging at both vegetative and flowering stage and also the same trend of jassid and whitefly were observed at both stages of the crop. Surrounding habitats showed non-significant effect on population densities of insect pests and predators. For abiotic factors, the spiders showed strong positive correlation with humidity and temperature. However, green lacewing was only positively correlated with humidity. On the other hand, the populations of whitefly, jassid and thrips showed non-significant correlation with both temperature and humidity. Overall densities of sucking insect pests were found above economic threshold level. The plant age, crop stage and surrounding habitats effect on the population fluctuation of pests as well as the predators' abundance. The future studies are also warranted to investigate the altered habitats and multiple trap cropping to find out their impact on unattended insect predators and parasitoids in cotton crop.

Induction of secondary metabolites on nanoparticles stress in callus culture of Artemisia annua L

Nanoparticles are known bio elicitors in plant biotechnology. Different concentrations of ZnO, CuO and CoO nanoparticles were used for the enhanced accumulation of secondary metabolites and antioxidant activities in the callus derived from root, shoot and leaf of Artemisia annua L. Biomass of callus was somehow affected on high concentrations of Nps. Phenolic content was observed maximum (60µg) in shoot callus at 0.1mg/l of CuONps. Total antioxidant activity was observed maximum (33µg) in root callus at 0.1mg/l of ZnOnps. Total reducing power maximum (33µg) was observed in root callus at concentration of 0.05 mg/l of CoONps. Maximum radical scavenging activity was observed in shoot callus at 0.05mg/l of ZnONps. Rutin gallic acid and caffic acid were also determined in most of the samples by HPLC. The study concludes that different Nps have positive effect on the induction of secondary metabolites in A.annua plant.

Euphlyctis Cyanophlyctis Schneider, 1799 (Amphibia: Dicroglossidae) in district Lower Dir, Pakistan

Euphlyctis cyanophlyctis (the skittering frog) is one of the most widespread species in Pakistan. Present study was aimed to know the presence of Euphlyctis cyanophlyctis in urban and rural areas of Lower Dir, the North-western Pakistan. A total of 33 frogs were collected, including 15 from rural and 18 from urban areas. The frogs were caught by hands covered with gloves instead of using nets. The collection was managed from August to October 2016 and from April to May 2018. Morphometric analysis, coloration as well as photographs of the frogs have been provided in detail. Skittering frogs were seen frequent in swampy areas near the water bodies. These frogs were mostly seen after sunset.

In-vitro and in-vivo evaluation of the antibacterial potential of Typha elephantina

The present study was aimed to evaluate the in-vitro and in-vivo antibacterial effects of the Typha elephantina aqueous extract (TE.AQ), ethanolic extract (TE.ET) and T. elephantina methanolic extract (TE.ME) against eight selected clinical pathogens. The test samples were tested for in-vitro analysis (by disc diffusion method) at different concentrations of 5, 15, 25, 50 and 100 mg/dL against both gram positive and gram-negative strains. The highest potential was observed in TE.ME at a concentration of 100 mg/dL against Pseudomonas aeruginosa exhibiting 19.67 ± 0.577 mm zone of inhibition (ZOI). The same fraction also showed good activity against Staphylococus aureus with ZOI of 17.50 ± 0.70 mm. The TE.ET was found most active against P. aeruginosa and Streptococcus pyogenes having ZOI of 18.53 ± 0.503 and 16.2 ± 1.55 mm respectively at a concentration of 100 mg/dL. The most sensitive bacteria P. aeruginosa was selected for in-vivo study (using poultry chicks) for induction of infection in chicks. The effects of TE.AQ, TE.ET and TE.ME were determined at concentrations of 300 mg/kg body weight based on hematological parameters, liver enzymes and gross pathological findings of lungs and livers. The findings of the in-vivo study in chick's model showed that treatment of experimental animals with TE.ME significantly restored the hematological parameters, liver enzymes and architecture of lungs and livers. Based on scientific evidence, the current study suggests that TE.ME may serve as a best and new natural antibacterial agent and can be used against infections caused by P. aeruginosa.

Comparative forensic analysis of reverse root canal filing and conventional method for DNA isolation from extracted teeth under different environmental conditions: A prospective study

The grinding of a whole tooth specimen has been considered the conventional method to extract genomic deoxyribonucleic acid (DNA) in forensic science. However, we have tried the less destructive reverse root canal filing (RRCF) method without disturbing the morphology of the tooth to achieve competent amplifiable DNA. A total of 27 pairs of bilateral intact extracted teeth from the same subject were used in three different simulated environmental conditions for the respective RRCF and conventional methods: (a) soil burial for six months, (b) incineration at 200º C for four minutes, and (c) immersion in water for two months. Qualitative agarose gel electrophoresis assessment and downstream amplification were performed. The results showed significantly higher mean DNA concentration for the RRCF method in all three environmental conditions (p value = 0.008) in comparison to the conventional method. However, comparable qualitative results were found in both methods for the mean DNA concentration for incinerated (159.49 ng/ml), soil (119.52 ng/ml), and water (108.60 ng/ml) samples. It was concluded that the RRCF method is better quantitively (ng/ml) and comparable in terms of quality with respect to the conventional method, with the added advantage of preservation of the tooth morphology.

Evaluating mobile conditional cash transfers for improving immunization coverage in Pakistan

Background

Despite progress in increasing immunization coverage, poor uptake of vaccines remains a challenge, particularly in LMICs. In part, this is due to the poor socio-economic status of caregivers, lack of motivation, and parental procrastination. While there is evidence that large (≥100 USD) incentives can overcome these problems, research on small incentives that are more appropriate for an LMIC setting is sparse. Our study addresses this gap by evaluating the impact of small (≤12 USD) CCTs in increasing immunization coverage for children under the age of two.

Methods

A 2-year program utilizing two small incentive schemes of different amounts (high: USD9; low: USD5) was implemented in Shikarpur District, Pakistan. Caregivers (with children 0-24 months) visiting any of the 33 study immunization centers were given the opportunity to enroll. All consenting parent-child pairs were randomized in one of the two incentive schemes and incentives were disbursed following each immunization visit, using mobile money. A baseline and end-line survey was conducted to evaluate changes in pre-post coverage.

Results

A total of 63,336 participants were enrolled between March 2016 - April 2018, of which 41,483 were randomized in the high or low incentive schemes (remaining caregivers were enrolled in the no-incentive group). Results show a 13% and 28% increase in age-appropriate coverage for Measles-1 (M1) and fully immunized children (FIC) compared to the baseline (FIC:16%, M1: 38%). There was no difference in M1 coverage between the high and low incentive schemes.

Discussion

Small CCTs have induced positive behavioral change and are a powerful tool for improving immunization coverage and compliance within LMICs.

Key messages

Small mobile conditional cash transfers (USD&lt;12) can serve as nudges to parents and lead to behavioral shifts resulting in improved immunization outcomes for children. There was no significant difference in outcomes between high and low incentives, indicating that small mobile conditional cash transfers were equally effective in improving immunization coverage.

Application of a new system for classifying root canal morphology in undergraduate teaching and clinical practice: a national survey in Malaysia

AIM

To evaluate and compare the feedback of final year undergraduate dental students in eight Malaysian dental schools on the application of a new system for classifying root canal morphology in teaching and clinical practice.

METHODS

One PowerPoint presentation describing two classification systems for root canal morphology (Oral Surgery Oral Medicine Oral Pathology, 1974 38, 456 and its supplemental configurations, International Endodontic Journal 2017, 50, 761) was delivered to final year undergraduate dental students in eight dental schools in Malaysia by two presenters (each presented to four schools). To examine students' feedback on the utility of each system, printed questionnaires consisting of six questions (five multiple choice questions and one open-ended question) were distributed and collected after the lecture. The questionnaire was designed to compare the classification systems in terms of accuracy, practicability, understanding of root canal morphology and recommendation for use in pre-clinical and clinical courses. The exact test was used for statistical analysis, with the level of significance set at 0.05 (P = 0.05).

RESULTS

A total of 382 (out of 447) students participated giving a response rate of 86%. More than 90% of students reported that the new system was more accurate and more practical compared with the Vertucci system (P < 0.001). Overall, 97% of students reported the new system helped their understanding of root and canal morphology compared with the Vertucci classification (P < 0.001). Over 97% of students recommended the use of the new system in teaching, pre-clinical courses and clinical practice (P < 0.001). Except for two schools, no significant difference was detected between the responses of students for all questions at the different schools (P > 0.05). The students' responses for all questions were almost similar for both presenters (P > 0.05).

CONCLUSIONS

The new system of International Endodontic Journal 2017, 50, 761 for classifying root and canal morphology was favoured by final year undergraduate dental students in Malaysia. The new system has the potential to be included in the undergraduate endodontic curriculum for teaching courses related to root and canal morphology.

Hypophosphatasia: Canadian update on diagnosis and management

Hypophosphatasia (HPP) is a rare inherited disorder of bone and mineral metabolism caused by loss of function mutations in the ALPL gene. The presentation in children and adults can be extremely variable and natural history is poorly understood particularly in adults. Careful patient evaluation is required with consideration of pharmacologic intervention in individuals meeting criteria for therapy.

INTRODUCTION

The purposes of this review are to present current evidence regarding the diagnosis and management of hypophosphatasia in children and adults and provide evidence-based recommendations for management.

METHOD

A MEDLINE, EMBASE, and Cochrane database search and literature review was completed. The following consensus recommendations were developed based on the highest level of evidence as well as expert opinion.

RESULTS

Hypophosphatasia is a rare inherited disorder of bone and mineral metabolism due to loss of function mutations in the tissue non-specific alkaline phosphatase (ALPL) gene causing reductions in the activity of the tissue non-specific isoenzyme of alkaline phosphatase (TNSALP). Deficient levels of alkaline phosphatase result in elevation of inhibitors of mineralization of the skeleton and teeth, principally inorganic pyrophosphate. The impaired skeletal mineralization may result in elevations in serum calcium and phosphate. Clinical features include premature loss of teeth, metatarsal and subtrochanteric fractures as well as fragility fractures. Poor bone healing post fracture has been observed. Myalgias and muscle weakness may also be present. In infancy and childhood, respiratory and neurologic complications can occur.

CONCLUSIONS

HPP is associated with significant morbidity and mortality. Pharmacologic intervention can result in significant clinical improvement. This Canadian position paper provides an overview of the musculoskeletal, renal, dental, respiratory, and neurologic manifestations of hypophosphatasia. The current state of the art in the diagnosis and management of hypophosphatasia is presented.

Correction to: Hypophosphatasia: Canadian update on diagnosis and management

In the article mentioned above an author's name was misspelled.

Genetic polymorphism of 15 autosomal short tandem repeats in Baloch population of Pakistan

Allele frequencies and forensic statistical parameters of 15 autosomal short tandem repeats (STRs) were evaluated in 200 genetically unrelated individuals of the Baloch population of Pakistan. Total 155 alleles were observed with allele frequencies ranged from 0.003 to 0.425. Among the 15 STRs, D2S1338 was found to be the most polymorphic and discriminating locus while TPOX was the least polymorphic and discriminating locus. The combined power of discrimination (CPD), combined power of exclusion (CPE), and combined matching probability (CMP) were found to be 0.9999999999999999978, 0.999994252, and 2.14012 × 10^-18, respectively. No significant deviation from Hardy-Weinberg Equilibrium (HWE) was observed except for locus D21S11. Additionally, a correlation between previously published data and Baloch population is also presented.

Autologous fat transplantation alters gene expression patterns related to inflammation and hypoxia in the irradiated human breast

BACKGROUND

Radiation-induced fibrosis, an adverse effect of breast cancer treatment, is associated with functional and cosmetic impairment as well as surgical complications. Clinical reports suggest improvement following autologous fat transplantation, but the mechanisms underlying this effect are unknown. A global gene expression analysis was undertaken to identify genetic pathways dysregulated by radiation and evaluate the impact of autologous fat transplantation on gene expression.

METHODS

Adipose tissue biopsies were taken synchronously from irradiated and contralateral non-irradiated breasts, before and 1 year after autologous fat transplantation. Whole-genome gene expression analyses were performed, and Hallmark gene set analysis used to explore the effect of radiotherapy and autologous fat transplantation on gene expression.

RESULTS

Forty microarrays were analysed, using bilateral biopsies taken from ten patients before and after autologous fat transplantation. Forty-five pathways were identified among the 3000 most dysregulated transcripts after radiotherapy in irradiated compared with non-irradiated breast (P ≤ 0·023; false discovery rate (FDR) no higher than 0·026). After autologous fat transplantation, 575 of the 3000 genes were again altered. Thirteen pathways (P ≤ 0·013; FDR 0·050 or less) were identified; the top two canonical pathways were interferon-γ response and hypoxia. Correlative immunohistochemistry showed increased macrophage recruitment in irradiated tissues.

CONCLUSION

The present findings contribute to understanding of how autologous fat transplantation can ameliorate radiation-induced fibrosis. This further supports the use of autologous fat transplantation in the treatment of radiation-induced fibrosis. Surgical relevance Clinical studies have indicated that autologous fat transplantation (AFT) stimulates regression of chronic inflammation and fibrosis caused by radiotherapy in skin and subcutaneous fat. However, there is a paucity of biological evidence and the underlying processes are poorly understood. Human data are scarce, whereas experimental studies have focused mainly either on the effect of irradiation or AFT alone. The present results indicate that radiotherapy causes dysregulated gene expression in fibrosis-related pathways in adipose tissues in humans. They also show that AFT can cause a reversal of this, with several dysregulated genes returning to nearly normal expression levels. The study provides biological evidence for the impact of AFT on radiation-induced dysregulated gene expression in humans. It supports the use of AFT in the treatment of radiation-induced fibrosis, associated with severe morbidity and surgical challenges.

Build better bones with exercise (B3E pilot trial): results of a feasibility study of a multicenter randomized controlled trial of 12 months of home exercise in older women with vertebral fracture

We pilot-tested a trial of home exercise on individuals with osteoporosis and spine fracture. Our target enrollment was met, though it took longer than expected. Participants stayed in the study and completed the exercise program with no safety concerns. Future trials should expand the inclusion criteria and consider other changes.

PURPOSE

Osteoporotic fragility fractures create a substantial human and economic burden. There have been calls for a large randomized controlled trial examining the effect of exercise on fracture incidence. The B3E pilot trial was designed to evaluate the feasibility of a large trial examining the effects of home exercise on individuals at high risk of fracture.

METHODS

Community-dwelling women ≥ 65 years with radiographically confirmed vertebral compression fractures were recruited at seven sites in Canada and Australia. We randomized participants in a 1:1 ratio to a 12-month home exercise program or equal attention control group, both delivered by a physiotherapist (PT). Participants received six PT home visits in addition to monthly phone calls from the PT and a blinded research assistant. The primary feasibility outcomes of the study were recruitment rate (20 per site in 1 year), retention rate (75% completion), and intervention adherence rate (60% of weeks meeting exercise goals). Secondary outcomes included falls, fractures and adverse events.

RESULTS

One hundred forty-one participants were recruited; an average of 20 per site, though most sites took longer than anticipated. Retention and adherence met the criteria for success: 92% of participants completed the study; average adherence was 66%. The intervention group did not differ significantly in the number of falls (IRR 0.97, 95% CI 0.58 to 1.63) or fragility fractures (OR 1.11, 95% CI 0.60 to 2.05) compared to the control group. There were 18 serious adverse events in the intervention group and 12 in the control group.

CONCLUSION

An RCT of home exercise in women with vertebral fractures is feasible but recruitment was a challenge. Suggestions are made for the conduct of future trials.

Genetic analysis of 15 autosomal STRs in Yousafzai population of Pakistan

Yousafzai is a Pushto-speaking Pathan tribe inhabiting the northern province of Pakistan who claim to be descendants of the prophet Yousaf (Joseph). Forensic and genetic parameters were determined for 203 genetically unrelated individuals on 15 autosomal STRs. D2S1338 was the most discriminating locus whereas TPOX was the least. The combined matching probability (CMP) for all loci was 1.52458 × 10^-18 while combined power of discrimination (CPD) and combined power of exclusion (CPE) was 0.9999999999999999984 and 0.999998628, respectively. The Yousafzai population was in Hardy-Weinberg equilibrium after Bonferroni correction except for loci D3S1358 and D19S433. Pairwise genetic distance analysis was carried out by comparing with various populations at local and global levels. The findings of this study are valuable for population genetics and forensics analysis.

Feasibility study of combined dynamic imaging and lymphaticovenous anastomosis surgery for breast cancer-related lymphoedema

BACKGROUND

Breast cancer-related lymphoedema (BCRL) presents a significant healthcare burden and adversely affects quality of life of breast cancer survivors. A prospective feasibility study was performed on lymphaticovenous anastomosis (LVA) for the treatment of BCRL.

METHODS

Patients with BCRL underwent near-infrared spectroscopy with indocyanine green lymphatic mapping to identify suitable lymphatic channels for LVA. End-to-end anastomoses to subdermal venules were performed and patients recommenced compression garment therapy (CGT) after surgery. Volumetric assessment of the affected limb was performed at regular intervals using infrared perometry to calculate the excess volume reduction.

RESULTS

Over a 24-month interval, 27 patients with BCRL underwent LVA. The mean duration of lymphoedema was 3·5 (range 0·5-18) years, and the mean number of LVAs performed was 3 (range 2-5). Twenty-four of the 27 patients completed 12-month follow-up. Patients exhibited three patterns of volumetric response following LVA: sustained response (16 patients), transient response (5) or no response (6). Sustained responders showed an excess volume reduction of -33·2 per cent at 12 months, and this correlated positively with the number of LVAs performed (r = -0·56, P = 0·034). Overall, ten patients were able to downgrade CGT after surgery, and two patients were CGT-free at 12 months.

CONCLUSION

LVA resulted in a sustained volume reduction in selected patients and may offset the burden of CGT. Further work is required to identify biomarkers that predict a favourable response to LVA surgery.

Association of burnout with doctor-patient relationship and common stressors among postgraduate trainees and house officers in Lahore-a cross-sectional study

Introduction

Burnout is defined as a prolonged state of physical and psychological exhaustion. Doctors, due to the demanding nature of their job, are susceptible to facing burnout, which has far reaching implications on their productivity and motivation. It affects the quality of care they provide to patients, thus eroding the doctor-patient relationship which embodies patient centeredness and autonomy. The study aims at addressing the stressors leading to burnout and its effect on the doctor-patient relationship.

Methods

A descriptive, cross-sectional study design with convenience (non-probability) sampling technique was employed in six major hospitals of Lahore, Pakistan. A total of 600 doctors were approached for the study which included house officers or "HOs" (recent graduates doing their 1 year long internship) and post-graduate trainees or "PGRs" (residents for 4-5 years in their specialties). Burnout was measured using the Copenhagen Burnout Inventor (CBI) while attitudes towards the doctor-patient relationship was measured using the Patient Practitioner Orientation Scale (PPOS), which measures two components of the relationship: power sharing and patient caring. Pearson correlation and linear regression analysis were used to analyze the data via SPSS v.21.

Results

A total of 515 doctors consented to take part in the study (response rate 85.83%). The final sample consisted of 487 doctors. The burnout score was not associated with the total and caring domain scores of PPOS (P > 0.05). However, it was associated with the power sharing sub-scale of PPOS. Multiple linear regression analysis yielded a significant model, by virtue of which CBI scores were positively associated with factors such as female gender, feeling of burn out, scoring high on sharing domain of PPOS and a lack of personal control while CBI scores were negatively associated with private medical college education, having a significant other, accommodation away from home and a sense of never ending competition. Burnout levels varied significantly between house officers and post graduate trainees. Twenty-three percent of the participants (mostly house officers) had high/very high burnout levels on the CBI (Kristenson's burnout scoring). Both groups showed significant differences with respect to working hours, smoking status and income.

Conclusion

Although burnout showed no significant association with total and caring domain scores of PPOS (scale used to assess doctor-patient relationship), it showed a significant association with the power sharing domain of PPOS suggesting some impact on the overall delivery of patient care. Thus, it necessitates the monitoring of stressors in order to provide an atmosphere where patient autonomy can be practiced.

Association of CD14 and macrophage migration inhibitory factor gene polymorphisms with inflammatory microRNAs expression levels in ankylosing spondylitis and polyarthralgia

This study aimed to investigate the genetic basis of ankylosing spondylitis (AS) and polyarthralgia (PA) conditions among Indian subjects through genotyping two immune regulatory genes CD14 (-159C>T) and MIF (-173G>C) and find their association with the expression levels of three circulating inflammatory miRNAs. This investigation may provide early genetic cause of these two forms of arthritis and more optimal biological targets to predict early therapeutic outcomes. A total of 140 patients (AS: 70 and PA: 70) and 156 controls were recruited from Indian population. CD14 and MIF genotyping was performed using ARMS-PCR. Expression level of three inflammatory miRNAs (miRNA-146a, miRNA-155 and miRNA-181) was quantified using RT-qPCR. C/T genotype of CD14 gene was found to cause 2.06-fold risk of developing AS (CI 1.06-5.98, p = .04) as compared to others and G/C genotype in MIF also shown significant variation between AS and control subjects. In PA subjects, CD14 genotypes (C/T) was found to be associated with disease susceptibility and G/C genotype of MIF gene polymorphism showed 4.71-fold risk of developing PA (CI 2.58-8.62, p = .0001). The study also revealed significant upregulation of miRNA-155 expression in AS subjects (p = .0001) with more than 1.3-fold difference between AS and PA as compared to the control subjects. miRNA-155 had strong association with AS patients with CD14 genotypes (p < .05) than PA and control subjects. This study provides better understanding of the mechanisms and disease susceptibility for MIF and CD14 genetic variants and inflammatory miRNAs networks involved in AS and PA.

Hip fracture surgery in mixed-use emergency theatres: is the infection risk increased? A retrospective matched cohort study

Introduction The National Institute of Health and Care Excellence recommends that people with hip fracture should have surgery on the day of, or the day after, admission. However, there remains unacceptable variation in performance around the country, with a range of 13-91% of patients meeting this target. Dedicated trauma lists have insufficient capacity in many hospitals. We occasionally employ a mixed-use emergency theatre to facilitate early surgery. Increased risk of infection has been raised as a concern owing to microbial surface contamination from a preceding unclean case and lack of laminar flow in these theatres. The objective of this study was to investigate whether there is an increased risk of surgical site infections in patients who had hip fracture surgery in a mixed-use emergency theatre. Methods Between August 2010 and July 2014, 74 patients had hip fracture surgery in a mixed-use emergency theatre without laminar flow. This group was compared with a control group of patients who had hip fracture surgery in dedicated orthopaedic theatres with laminar flow. Infection was the primary outcome measured. Results There was no statistically significant difference in the rate of infection, length of stay or 30-day mortality, readmission or reoperation rates between the two groups. Conclusions Operating on hip fractures in mixed-use theatre did not lead to an increase in infection or other complications in our series. We feel that the risk of infection can be balanced against advantages of timely operation and it may therefore be justified to use these theatres when faced with lack of time on the trauma list. A much larger series would be required to investigate the effects of confounders.

Shunting of the over 80s in normal pressure hydrocephalus

BACKGROUND

Idiopathic normal pressure hydrocephalus is predominantly a disease of the elderly. By its nature, many of those who present to clinic are in advanced old age with multiple comorbidities. Majority of patients treated are younger than 80 years old. We present the clinical outcomes and complication rates of patients over the age of 80 years at the time of operation, during the past 11 years at a single institution.

METHODS

Retrospective analysis of clinical records of all patients over the age of 80 years, who presented to our institution between 2006 and 2016. Results were analysed for co-morbidities, immediate and delayed complications, change in mobility/cognitive function post shunting of hydrocephalus.

RESULTS

39 patients (24 male, 15 female) met criteria. Mean [SD] age at the time of shunt insertion was 84 years (+/- 3.22) (range 80-94). No patients developed immediate CSF infection or sub-dural collection, or extended length of stay due to surgical or anaesthetic complications. There were no peri-operative or anaesthetic complications. 4 patients required a delayed surgical revision to encourage greater CSF drainage. 3 patients went on to develop delayed subdural haematoma, 1 of which was associated with trauma, 2 through overdrainage. 1 patient experienced poor post-operative wound healing and subsequently underwent removal of shunt. Of the 34 patient followed up, 27 patients (79.4%) improved in their mobility. (64.7%) patients/families reported symptomatic improvement in their cognition and memory. 6 (17.7%) patients did not experience an improvement in either mobility or cognitive function.

CONCLUSIONS

Our data supports the assertion that, with proper patient selection, shunting of the over 80s with iNPH is a safe and effective procedure.

Primary hyperparathyroidism: review and recommendations on evaluation, diagnosis, and management. A Canadian and international consensus

The purpose of this review is to assess the most recent evidence in the management of primary hyperparathyroidism (PHPT) and provide updated recommendations for its evaluation, diagnosis and treatment. A Medline search of "Hyperparathyroidism. Primary" was conducted and the literature with the highest levels of evidence were reviewed and used to formulate recommendations. PHPT is a common endocrine disorder usually discovered by routine biochemical screening. PHPT is defined as hypercalcemia with increased or inappropriately normal plasma parathyroid hormone (PTH). It is most commonly seen after the age of 50 years, with women predominating by three to fourfold. In countries with routine multichannel screening, PHPT is identified earlier and may be asymptomatic. Where biochemical testing is not routine, PHPT is more likely to present with skeletal complications, or nephrolithiasis. Parathyroidectomy (PTx) is indicated for those with symptomatic disease. For asymptomatic patients, recent guidelines have recommended criteria for surgery, however PTx can also be considered in those who do not meet criteria, and prefer surgery. Non-surgical therapies are available when surgery is not appropriate. This review presents the current state of the art in the diagnosis and management of PHPT and updates the Canadian Position paper on PHPT. An overview of the impact of PHPT on the skeleton and other target organs is presented with international consensus. Differences in the international presentation of this condition are also summarized.

Sero-prevalence of Hepatitis B and C Virus from rural areas of northern Punjab (Sargodha District), Pakistan

Pakistan is endemic for hepatitis B virus (HBV) and hepatitis C virus (HCV) infections with 10 and 11 million infections, respectively. The epidemiological studies of these virus showed that the information is only from few cities of the country and is relevant to high risk groups. It is of great importance to have an idea about the prevalence of infectious agents in general population to help in identification of hot spot for infections. Identification of hot spots will help in disease management for future. As the there is no report form district Sargodha (Punjab Province) so this study was designed to analyze the prevalence of HBV and HCV in general population. Blood samples of 2373 randomly selected individuals from six different tehsils were collected and were analyzed for HBV and HCV sero-positivity. An overall prevalence of both HBV and HCV in district Sargodha was 28.10% (667/2373). HCV prevalence was (20.01%) and HBV seropositivity was (8.09%). Males were more infected than females, and a significant difference was found in positive cases between male (58.77%) and female (41.22%). The most common routes of transmission of hepatitis virus in present study were shaving assisted by barbers in male patients 143 (21.43%), non sterile or used needles and syringes 127 (19.04%), dental surgical procedures 88 (13.19%), and sharing razors in males 49 (7.34%). In female patients a significant factor is labor and child birth process. Most cases of hepatitis were seen in mesons, farmers and house wives. The prevalence of HBV and HCV in general population of district Sargodha is very high. The study will help for better management of disease to contain the disease spread. The study highlighted that District Sargodha is endemic for these viral infections and it is highly warranted to carry out more studies to get better idea about the infection spread. Community education campaigns are also highly warranted to general population as well as high risk population to control future disease spread.

Amoxycillin in the Treatment of Childhood Pneumonia

Amoxycillin ('Amoxil') a new semi-synthetic penicillin was used in the treatment of pneumonia in 30 children. A very satisfactory clinical cure was effected in all cases on a dosage requirement of 125 mg eight hourly for 5-8 days.

There were no side-effects. In view of its regimen of three times daily dosage, proven efficacy and facility of administration with food it should be usefully recommended for routine out-patient/in-patient therapy of childhood pneumonia.